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_ APPLICATION FOR PERMIT <br /> ?jpn?_4 el D <br /> SAN JOAQUIN COUNTY PUBLIC HEBS <br /> 9a's ENVIRONMENTAL HEALTH DI Icbdqff <br /> 'J'A 445 N SAN JOAQUIN, PHONE {20 )) ( 420 <br /> P O BOX 2009., S,TOCKTON, C Z <br /> � ���+EA� � PERMITE%PIRE D <br /> 4 q,A (Complete in Triplica e- <br /> N) <br /> Aa-tion is hereby made to San Joaquin County for a permit to construct ifa r n e <br /> application is :rode in cotwilance with San Joaquin County Ordinance No. 549 a es an Aegulatione of San <br /> Joaquin County Public Health Services. <br /> 200' S/0 PETER MILLER RD.&150'E/O I-5 <br /> Job Address City Lot Size/Acreage <br /> Owner's Name CHEVRON PIPELINE COMPANY Address 2360 BUCHANAN RD. _ Phone —6195 <br /> ERICAN _ 38 <br /> ontractor_CQNST_ R ST1PPT:Y INC Address�8 RRT) OOD HWY-#2 License No. �T C —W 1'. - -Phone <br /> TYPE OF WELL/PUMP: NEW WELL JX WELL REPLACEMENT n DESTRUCTION D out of Service Raja ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well l7 <br /> DISTANCE TO NEAREST: SEPTIC TANK _ N/A SEWER LINES N/A DISPOSAL F-LD. NZA PROP. LINE N/A <br /> FOUNDATION �N A AGRICULTURE WELL -NJ-A-- OTHER WELL N/A PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> C Industrial ❑ Open Bottom C Manteca Dia. of WON Excavation- IQTTDia. of Wall Casing " <br /> is Oom*stic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_--21;c Specifications SC'.H A0 <br /> l'1 Public ff oiher CATHODIC n Dalt, Depth of Grout Seal - -100 Type of Grout 6r' l <br /> I I Irrigation Approx. Depth I 1 Eastern Surface Seal Installed by TREMTF <br /> Repair Work Done * Type of Pump H.P, State Work Done <br /> Well Destruction ❑ Weil Diameter Sealing Material A Depth <br /> CATHODTC Depth F111er Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (NG septic system permitted if public sewer is <br /> N/A available within 2413 lest.) <br /> Installation will serve: Residence_ Commercial— Other <br /> Number of Nving units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK Cl Type/Mfg17 0.1/11Ia. Compartments F <br /> PKG. TREATMENT PLT. 11 � , othod of Disposal y1�� <br /> Distance to nesrest: NVWlrrda Property Line <br /> LEACHING LINE ❑ No. A Length of lines t /size <br /> FILTER BED N/A p Distance to nearest: r/ aililvlr 12 <br /> ��Imy Fi 'd r party Line <br /> �i�4d� _ <br /> SEEPAGE PITS 11 Depth Size Number- <br /> SUMPS N/A LI Distance to nssrost: Well Foundation__ Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application end that the work will be done.in:accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin County <br /> Horne owner or licensed agent's iignatur*certifies the following: "I certify that in the performance of the work toe which this permit is issued, I shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California."ContractoPs hiring or sub contracting signature <br /> eortiflas the following: -I unify that in performance of the work for which this permit is issued, 1 shall*mploy persons subject to workman's componso- <br /> tion laws of Califor la," <br /> The applicant t 11 f req ad in"ctions. Complete drawing on reverse side. <br /> Signed x- �/ STEVE McKIM Title: PROJECT MANAGER Date: _11/30193 <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date -3Area <br /> Pit or Grout inspection by Date Final Inspection by Oats <br /> Additional Comments: - <br /> r <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health PermitlServlcee <br /> 445 N San Joaquin, P 4 Box 2009„ Stkn, CA 95 <br /> FEE <br /> 6 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. �7 1 <br />